When will more Doctors stand up for their Patients and Themselves?

I walked into the hospital for my overnight shift through the ER. Always good to know what surprises they have in store for you. My colleague, whom I was relieving, looked upset. She gave me the thumbnail: “Four month-old there nearly three hours, looking toxic. Studies all in the lab, fluid bolus on board, BP acceptable, not great. Pharmacy won’t mix and send antibiotics, stating the ER’s computerized ordering system (CPOE) isn’t communicating with theirs.”

A simple problem – “Haven’t you called the pharmacy and asked for the antibiotic?”

“Yes, but this week, CPOE is in full operation. Administration mandates only electronic orders are acceptable.”

Ah, yes, our good friend the EHR. Several years earlier, our hospital converted to electronic notes. As a hospitalist, it wasn’t bad, except on busy nights. I sat with each family, looked them in the eye, jotted down notes, examined the patient, and then entered my note into the system. The system was decent. For physicians in practice it was harder: seeing 40+ patients daily, face-to-face patient encounters morphed into face-to-computer screen encounters, madly checking off boxes. (Where did the patient go?)

At endless meetings during our hospital’s enforced transition to CPOE, we saw screenshots of the system: awful! Every time I asked ‘why’, I was met with eye rolls and told to “accept this wave of the future.” MIS people had to train each physician (didn’t cost us a dime for this fabulous educational activity, but our MIS friends were no doubt paid for their time).

We entered a months-long period of CPOE trial. It took us far longer to ‘write’ orders under this system, and with each set of orders came a dozen pager beeps of questions from the nurses, pharmacy, and respiratory therapists. Soon came beeps from MIS telling us everything we did wrong.

Worst of all…the mistakes. A patient got Clonidine instead of Klonopin. Entire therapies weren’t administered, because in my haste to run to an emergency, I neglected to click on the correct drop down menu for pulmonary toilet. There were more mistakes under CPOE than I’ve ever seen in medicine. Whenever I raised my hand at meetings, I was nearly the only one complaining. We were told nuances of CPOE were beyond repair; they were part of the system the hospital purchased. (The billions made by software companies when EHRs became mandated must’ve been one doozy of a quid pro quo!)

Shocking, was the complacency of my fellow physicians. When did we become such puppets for our masters, the administrators? Hospitals and doctors need administration, but we don’t need the 4000% increase we’ve had since the 70’s.

Let’s get back to what really matters: the patient. At the moment I heard about not having crucial antibiotics for a sick infant, I snapped. I walked to the nearest phone and dialed the pharmacy, “Dr. Mass here. Why is patient x waiting for meds?”………(party line reply delivered)….”I see. You are going to mix up the antibiotics and get them to the ER in ten minutes. Otherwise, I will call the hospital CEO and tell him that I am going to tell the parents that their child is in danger because of hospital policy. I will not have some (un-publishable word) bureaucrat dictate my patient’s care. What? …Oh, thank you.” Coming clean to let you know how fun and liberating that moment was, as the ER staff stared at me in shock.

I don’t wonder why more physicians don’t complain; it takes time. We are knee deep in CME, MOC, state and hospital mandates, insurance company fights, on and on. No wonder patients say we don’t take enough time with them. Furthermore, 80% of physicians are hospital-employed. Buck the system, lose a job. If you aren’t hospital-employed, you are bogged down keeping your indie practice alive for the sake of the patients you love.

Back to the patient, who should come before all else. We have an unsustainable system that patients can’t understand, and docs have no time or power to fix. The only scenario in which physicians will regain power is the zombie apocalypse, or the ISIS infiltration, whichever comes first. In either scenario, the bureaucrats will no longer be useful, as they will be unable to deliver babies, remove appendixes, etc.

To physicians who remain complacent–allowing our current health care death spiral by not telling our patients and colleagues the truth, please find your voice. Unleash the power of your training and experience, and speak up. Ask your future self, amidst the rubble of tomorrow’s health care system , if you did the right thing by remaining silent. We owe thanks to the brave ones who fight.

There is a beautiful passage in Shakespeare’s Henry V, young King Hal’s speech to the troops before the battle of Agincourt: “and we few, we band of brothers…gentlemen in England now a bed shall…hold their man-hoods cheap while any speaks that fought with us upon St. Crispin’s Day.” I have two teens who want to become doctors. Someday, they can look into their mother’s eyes and know that I fought to make their lives and those of their patients better.

My patient did well. Blood culture returned negative, but what if the patient was frankly septic, and continued to lack antibiotics? Would you want that to be your child? Your grandchild? So the question remains: ‘When will more doctors stand up for their patients and themselves?

Comments

Bill, Have you been on the no MOC website? Here in Pa, we have a st medical society that is very supportive of pulling down mod. You should also check out what is going on in Michigan, where Meg E, one of the Rebel MDs is really making progress… I will let her answer for herself! And for the real down and dirty, check out Dr Wes’s blog spot! Good luck!

The http://changeboardrecert.com site is very good for MOC information and for making contacts. Michigan State Medical Society is taking the MOC issue very seriously, just launched a public education campaign on issue to correspond with the legislation. right2care.org

I have been in medicine, since 1990, when ICD 9 coding and CPT were in books and the physicians taught how to do that, after many years working my way up into administration work, I decided to go back to school to become a provider. After 8 years into a 10 year degree, I LEFT MY PROGRAM! Why? It was just as broken as the MOC system. We were not treated as humans with a brain; instead we were TRAINED TO COMPLY! We were told that it is a “small community” and if we didn’t comply and quit questioning if any of this made sense, we would be blacklisted after graduation. I am an OLDER student, 42 at the time, mature and NOT moldable! I went back to school, not because I financially needed to, I went to become a great provider, but I found in this current day and age that is NOT what the schools are looking for. I was actually told by their administration that is why they don’t embrace older students, because we are not moldable! I am sitting next to mid 20 year olds, who DO NOT HAVE a voice, lived in fear and these are some of the most intelligent young adults I have ever known. When will everyone get it? When we run out of providers…when going to school and working over 80 hours a week studying and doing rounds is not longer worth it. There was no joy in patient care, instead I took the$100,000 I had saved up to pay my tuition and RETIRED at 45! I have such talent, such a gift, and unfortunately, it became my worst nightmare and I chose not to fall prey to “gamblers fallacy”, I chose NOT to participate in the broken system.

No disagreement here. When our hospital was pursuing CPOE, I noted in many meetings that adding only 1 minute of time per patient per day (optimistic) could add many DAYS of time for some groups. That fell on the deaf ears of my colleagues.

Thanks Scott… consider getting into your co or state medical society with like minded pals and reforming it to real change…or look up other doctor friendly sites…letmydoctorpractice.org, the benjamin rush institute AAPS and docs4patient care all jump right to mind!!!

This is not a problem with a simple solution. Standing up is not enough. A physician I know took his complaint past the CEO, all the way to the hospital system president. He described that patient care was being compromised due to regulations. He was told that “physicians of his generation” had unrealistic expectations of patient care.

Only those of “our generation ” are “physicians”. Newer “health care providers” are unaware of what medicine should be as they only “provide” a service dictated by the newest edition cookbook published by CPOE.

After you take it to the admin, and get a crappy response, don’t be afraid to send it to the media and state medical association, even the state attorney general. If they (admin) are aware that there may be legal consequences to their action, they will pay attention.

Physicians must resume leadership in medicine. Over the past few years I’ve been working with business schools to create business education for physicians around leadership (not management). As physicians we respect expertise but our confidence in those who would run medicine is misplaced. Give physicians the same training in business concepts that the hospital administrators have and the entire power balance is restored.

The first program is called PHYSICIAN CEO, it is held at the Kellogg School of Management at Northwestern University, and the 2016 program starts in a few weeks. Physicians only, fast paced and totally relevant. This program is for physicians in practice. Future programs will target medical students and residents.

We can complain to each other out we can take control. This is our time. Please engage.

Learning that few computer-based hospital information systems were highly successful, I read that Mayo Clinic Jacksonville Florida had implemented the first fully paperless system. How did this happen? “CEO was Leo Black, MD.”

Novel idea, but too expensive, in my opinion. Which community-practicing physician can afford to close office 2-3 days every quarter and pay 38K? Like myself, most mid-career docs likely are paying for their kids’ college tuition at the same time, and younger docs are still not done with their own college loan repayment. Like everything in life, there has to be a value proposition. Nice effort, though.

Thanks for the comment, Arvind. The PHYSICIAN CEO program has attracted a self-selected and non-random sample, so generalities are difficult, but so far we are seeing huge returns from the participants. Nearly all have made major changes in their practices and several have begun or scaled their medical-related enterprises (practice roll-ups, device companies, one is staring a hospital in China and revamping the national resident training program in ophthalmology, foundations for care in developing countries, etc.). The time and the tuition are trivial by comparison.

Business training is expensive. The Executive MBA tuition is nearly $200,000 for a two year program. The PHYSICIAN CEO program is a tremendous value, particularly given the custom design for physicians. (Frankly, people who work as hard as physicians do should not have to be concerned about a $38,000 pre-tax expense, or about taking time off. The system is upside down.)

What the PHYSICIAN CEO program is NOT is a training ground for hospital administrators, people who want to run ACOs, etc. This program is designed for people engaged in system change and entrepreneurial pursuits. Over 40% of medical costs today go to support reimbursement and compliance, and add minimal if any value to patient care. There are better ways to run medicine. Physicians must bring their values, their “brand” to the industry, and this program trains physicians to do so.

PHYSICIAN CEO isn’t for everyone. Not everyone is a Physician CEO. Many of our colleagues are happy to be called “providers” and be “managed” by bureaucrats. But for those who are frustrated with the system and want to make a difference the program has provided great value. To those who are concerned about the time or cost, I would raise the metaphor of “Covey’s saw.” Steven Covey is the author of “The Seven Habits of Highly Successful People.” If you aren’t familiar, here is a link to the Covey’s Saw metaphor: http://juvenate-ltd.com/lumberjack-story/effort

Thanks again for your comments! I appreciate your work with Rebel.MD and look forward to participating.

engaging, Guy…. Thanks for commenting!!! maybe you could send some of your graduates to the following places: (besides Rebel MD) Benjamin Rush Institute, letmydoctorpractice.org, AAPSonline and Docs4patient care. Docs are a diverse group and not every group will be the perfect fit for every physician. these are the four places I have found that are engaged and ready for action!!!

Here I am….was the first practice in my region to fully electronic in 2002, yet I’m not willing to sell myself through MU. No PQRS or VBM for me either, so I getting a 7% cut next year. So finally I get my chance to say good bye to Medicare.

Rallied is right. thousands of docs are doing this. Just not together, so ineffective. Time to get under one roof, and say No. No to MU, CPOE, PQRS, MACRA, etc. Tell your staff and family to brace for a decline in revenue for the short term, team up with your patients, offer them discounted office visits and use the free market.

Kudos! I’ve been fighting ‘city hall’ for so long, along side so many lemmings, that its truly has been taking the fight out of me. With the computer system at my hospital, where you have to hit return to get a carriage return to the next line in a free form field, yes like DOS, I just said, that’s it-stop seeing patients in hospitals! Couldn’t convince doctors to revolt against 20 yo software coming out of “Lowest Common Denominator, inc.” So many other thoughts, so little time! Keep rallying the troops!

Dude, we are rallied!!! Look at the following 4 organizations: AAPSonline.org, Benjamin Rush Institute, Docs4patient care and letmydoctorpractice.org Join us!!! As doctors we have relinquished our power because we have remained unorganized. This story is not even the story that hits closest to my heart and angers me the most…the story that does so is the story of how the system neglected my mother in her hour of need. Well it was a week of need. At an accoladed hospital. Shift after shift of neglect during the days when I was working, taking care of 3 kids, and could not make the 1 1/2 hour drive. I’m holding out for a big arena audience for that story!!!! Come join the fight!!!

I sound jaded, but in a seperate story, my mother was mismanaged. I reported to Joint Comissiona and DOH… Feeling good that I launched investigations… A year later, a friends mom was similarly mismanaged at the SAME hospital. It was bad enough that I as a doc could not prevent her mismanagement. But to have the ‘watchdog entities’ show that they were useless…. Well, dang! What do we do?

Those entities you listed are designed take their action according to the the modern hypothesis – the anti-Deming hypothesis. When failure occurs, the system is perfect but the individual is flawed. JCAHO, licensing boards and State pharmacy boards are designed to identify the defective INDIVIDUAL and neutralize him/her. The possibility for restructuring a defective SYSTEM is UN-necessary, by definition; systems only fail when humans mismanage them. The doctor who failed to administer the antibiotic will be punished. Welcome to the Brave New World.

If the consequence is risk of harm or death of the patient, what does the IT EMR modernized electronic system allow anyone to do? It allows for only the vanishingly small set of pre-programmed possibilities that it can execute. Otherwise, fate takes its course, and the patient passes away.. Compliance and obedience are more important than life and death.
How is this different from the ignorant witch-doctoring of millennia past?

EHR’s with user UNfriendly CPOE’s are very, very dangerous indeed. Excellent article, Dr Mass. CPOE (with no front desk help anymore) does not only prevent fast, easy ordering of common medical tests, procedures, and life-saving medications. CPOE discourages unusual order requests that might make a diagnosis, for example, Legionella pneumonia (urine Legionella antigen) instead of influenza or pneumococcal pneumonia, Cryptococcemia instead of bacterial septicemia (serum Cryptococcus antigen). Thus, CPOE’s are not only SLOWING DOWN routine orders and operations but also encouraging physicians to MISS CRITICAL DIAGNOSES beyond cookie cutter algorithms from common illnesses… which leads to excess, wrong antibiotics used, more patient suffering, prolonged hospitalizations, and perhaps more 30 day READMISSIONS if the correct diagnosis was not reached by the first discharge. Hospital patient care is served only when wise, experienced physicians and clinicians are leading hospital governance, including the Board of Trustees, to stop nonclinical, nonsensical EHR mandates from hurting patient care.

Regarding reporting to Feds: I bought out my contract 9 months in because of overt HIPPA violations, pill mill behavior, and a physician and his NP practicing wildly outside of their respective scope of practice. Hospital administrators put him on paid administrative leave. Later he ‘resigned’ after external review found him outside of SOC. NP had no repercussions from the Nursing Board for horrendous rx practice. CRS (HIPPA) folks did nothing-hospital claimed ‘we didn’t know better’ (2013?!). DEA report at same time–still haven’t heard back. The system is circling the drain. Happy to have found RebelMD!!

RNs do not like the fact the patient is just a box and a check mark either!! We ALL need to stand together and be the leaders of healthcare – not let overpaid CEO’s and IT tell us how to care for patients!